WAHIT Members Forms Library

Plan Description

Form

Premera Blue Cross Forms - NOT Located in Clark County

Request for Certification of Overage Dependent
For requesting certification of an overage (25+ years) dependent.  See your medical benefit booklet for more information.

PBC RX Mail Order

PBC RX Claim Form

PBC Medical/Dental Claim

LifeWise Health Plan of WA - Located in Clark County Only

LWHPW RX Mail Order

LWHPW RX Claim Form

LWHPW Medical/Dental Claim Form

Life and Disability Forms

Death Claim Form

Accelerated Death Form

Dismemberment Claim Form

Life Insurance Conversion Form
When no longer eligible for WAHIT group Life Insurance, you may convert all or part of your benefit amount to an individual life policy without evidence of insurability.

Waiver of Premium Form
LifeWise Assurance Company will waive your life insurance premiums on the employer paid coverage if you become disabled prior to your 60th birthday while you are insured under the plan, and after you have been continuously disabled for 6 months subject to due proof.

Domestic Partnership

Affidavit of Domestic Partnership
Employees that wish to add their domestic partners for insurance coverage whose partnership is not registered in the domestic partner registry of any state, should complete the appropriate form which should be retained by the employer for his/her records.  The employee should also submit an employee application indicating the addition to BSI.

Statement of Termination of Domestic Partnership
Employees that wish to delete their domestic partners for insurance coverage, should complete the appropriate form which should be retained by the employer for his/her records.  The employee should also submit an employee application indicating the deletion to BSI.